Welcome

Moderator: Julie Schilz, BSN, MBA

PCPCC Co-Chair, Center for PCMH Advancement Director, Patient Centered Care Transformation, WellPoint

The Medical Home Experience: Care Coordination and the Patient’s Role in Shared

Decision Making and Team Communication Supported by the Center for PCMH Advancement

Date: Thursday, July 12, 2012 Time: 1 – 2:30pm ET Speakers: Christine Bechtel

Vice President, National Partnership for Women & Families

Melinda K. Abrams, M.S. Vice President, Patient-Centered Coordinated Care Program The Commonwealth Fund

The Medical Home Experience: Care Coordination and the Patient’s Role in Shared

Decision Making and Team Communication Supported by the Center for PCMH Advancement

“I just want my doctors to talk to each other.” - Quote from forward by Christine Bechtel, Vice President

National Partnership for Women & Families

This report features 3 core elements: 1)  Expert-authored articles on the definition, role and

function of care coordination, as well as tools for implementation, and measurement and monitoring of its effectiveness.

2)  Case examples 3)  Summary of survey responses from select practices

The Medical Home Experience: Care Coordination and the Patient’s Role in Shared

Decision Making and Team Communication Supported by the Center for PCMH Advancement

Prior Appointments -  Vice President of eHealth Initiative (eHI) -  American Health Quality Association -  Senior Research Advisor, AARP

Community-based Quality Initiatives -  Director of Community Development, Louisiana’s

Medicare Quality Improvement Organization, Louisiana Health Care Review

Christine Bechtel Vice President National Partnership for Women & Families

The Medical Home Experience: Care Coordination and the Patient’s Role in Shared

Decision Making and Team Communication Supported by the Center for PCMH Advancement

The Commonwealth Fund -  Task Force on Academic Health Centers -  Commission on Women’s Health -  Child Development and Preventive Care programs -  Grant awards program to state Medicaid agencies Committees: -  Board of Managers for TransforMed -  Steering Committee for the Advanced Primary Care

Demonstration at the Center for Medicare and Medicaid Innovation

-  Medical Home panels for AHRQ

Melinda K. Abrams, M.S. Vice President The Commonwealth Fund

The Medical Home Experience: Care Coordination and the Patient’s Role in Shared

Decision Making and Team Communication Supported by the Center for PCMH Advancement

Before we begin…

• All lines have been placed on mute • Q&A session at end of event • Polling questions throughout

The Medical Home Experience: Care Coordination and the Patient’s Role in Shared

Decision Making and Team Communication Supported by the Center for PCMH Advancement

The Medical Home Experience: Care Coordination

Christine Bechtel Vice President

PCPCC Webinar July 12, 2012

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About us

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 National Partnership for Women & Families   National, non-profit, consumer organization with 40 years’ experience working on issues

important to women and families

 Campaign for Better Care   Engage patients and consumers in re-design of our health care delivery and payment

system   Particular focus on meeting the needs of high need/high cost populations – older adults,

complex chronic conditions   More than 150 national, state, and local organizations

Agenda

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 Overview of Medical Home consumer messaging research

  Patient-Centered Care   What does care coordination mean to patients?   Changing the paradigm; myth busting

 How we know if we’re getting care coordination right   Collaborative consumer engagement

  Focus groups and national survey to develop ways to talk about delivery system reform in 2009 (Health Affairs, May 2010)   Health IT   Medical Home   Payment Reform   Quality Measurement/Public Reporting   “Patient engagement” – shared decision making, patient experience

  Medical Home (aka: Medical Home-base: A team approach to providing care)   Favorable views because of emphasis on coordination and communication   Liked notion of a “point-person”   Resonated with treating the “whole person”   Concerns about how to pay for the model, gatekeeping, new fees   Liked “patient-centered” approach

Our Research

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 How confident are you that you can define the term “patient-centered care”?   Very confident   Somewhat confident   Not very confident   Not at all confident

Polling Question

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 How confident are you that your colleagues on this webinar would define it the same way?   Very confident   Somewhat confident   Not very confident   Not at all confident

Polling Question

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 Institute of Medicine  Care that is respectful of and responsive to individual patient

preferences, needs and values, and ensuring that patient values guide all clinical decisions.

 Planetree  An approach to the planning, delivery and evaluation of care grounded

in mutually beneficial partnerships among providers, patients and families. It redefines relationships in health care.

Patient-Centered Care Definitions

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 Consumers & consumer orgs:  Whole person care: clinicians understand the full range of factors

affecting a patient’s ability to get and stay well and treatment recommendations align with patients’ values, life circumstances and preferences

 Coordination and communication: providers organized in teams and smooth transitions between settings

 Patient support and empowerment: expanding patients’ and caregivers’ capacity to get and stay well and support for self-management tools and services

 Ready access: getting appointments promptly and accommodating barriers such as language or physical or cognitive problems

Consumer Definition

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  “My doctors talk to each other – and to me”

  A “go-to” person available to answer questions, help navigate system, and help patients understand their condition and what they need to do

  Help choosing specialists or other services and getting timely appointments   Having complete information at point of care; ensuring other providers have patient

information in advance   Providing patient and caregiver access to information

  Tracking referrals and results; helping patients understand recommendations and follow up actions

  Providers organized in teams to address patient needs comprehensively

  Patients and families know roles and responsibilities of team members

Coordination and Communication

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  Systems in place to prevent errors and duplication caused by multiple clinicians treating the same patient   Med reconciliation, electronic information exchange, shared medical records

 Helping patients with insurance eligibility, coverage and appeals (or referrals for assistance)

 Connecting patients to community resources (transportation, support groups, exercise programs, health literacy classes, etc.)

 Culture of “taking responsibility” for care coordination   Proactive, persistent, ongoing   Align actions of care team with patients’ health goals

Coordination and Communication, ctd.

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 Getting to effective care coordination and patient-centeredness requires debunking myths:

 Myth #1: Patients always want everything.

 Myth #2: What patients say they want is nice and important but we don’t have time – what matters is clinical outcomes.

 Myth #3: Doctors/clinicians know what patients want.

 Myth #4: If we just build the system the right way, they will come.

These patients want the moon!

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 How do/would you know if you’re getting care coordination “right?”   Because we implemented evidence-based practices   Because we got CMS/Other Payers to pay us for it   Because we asked patients and families and they said we were doing ok   Because we worked with patients and families to design and evaluate our processes

Polling Question

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Getting Care Coordination Right

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  Paradigm Shift: What we need is “Collaborative Consumer Engagement”

Collaboration = Partnership

Patient-Centered Care

 How do we get patients to tell us what they need us to do?

 Three Levels: 1.  Engagement in Care – partnership to better manage care and improve

health status based on patient’s own goals   shared decision making, joint goal setting, developing care plans

2.  Engagement in Practice Redesign – working to redesign practices of care

  care coordination, designing dx management programs, improving pt experience 3.  Engagement in Governance – setting policy for initiatives or

organizations   hiring staff, setting job descriptions, or setting qualification criteria or payment

policies for medical home initiative

….Right at Every Level

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  Jointly review, and develop solutions, in response to patient experience and other feedback data

  Engage patients/families in quality improvement and redesign efforts   Engage patients/families in developing and vetting patient information,

educational materials, websites/portals, care planning and support tools, including cultural/linguistic appropriateness

  Involve patients/families in staff orientation/training   Involve patient/family advisors in “walk-throughs” to assess care

delivery from patient perspectives

Examples of Partnership: Redesign

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  Designing, implementing and evaluating care coordination processes and results WITH patients and families is key

IT IS NOT:   Doing things for or to them, but not with them

  Getting consumers to do what we want them to do   Without them

  Consumer-Friendly/Patient-Focused Care   Providers still know best   Doing for patients

Collaborative Consumer Engagement

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Click to add title Collaborative Consumer Engagement Leads to Better Outcomes

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Consumers

Identification Training/ Support

Providers

“Champions” Training/ Support

Consumer-Provider Partnerships

Better Care Better Health ↓ Costs ↑ Clinician/Staff Satisfaction

Consumers gain skills to effectively partner with providers, and advocate for interventions that lead to better care outcomes

Providers build receptivity to, and skills for, working with consumers – emphasis on listening, understanding, and collaborating on shared goals.

Consumers exercise real influence on priorities & interventions that drive toward better care outcomes; Providers “hear” and engage with consumers as genuine partners. Together they develop shared goals and implement practices that improve care and achieve better outcomes for both patients and providers.

Examples:   • Jointly review, and develop solutions, in response to patient experience and other feedback data • Engage patients/families in QI and redesign efforts • Engage patients/families in developing and vetting patient information, educational materials, websites/portals, care planning and support tools, including cultural/linguistic appropriateness • Involve patients/families in staff orientation/training • Involve patient/family advisors in “walk-throughs” to assess care delivery from patient perspectives

 How likely are you now to partner with patients and families to design/redesign your care coordination strategies?   Very Likely   Somewhat Likely   I hope and pray we can   Not very likely (it’s ok to be honest)   Not at all likely (feel free to call me and discuss)

Polling Question

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For more information

Find us:

www.NationalPartnership.org www.CampaignforBetterCare.org | www.PaidSickDays.org

Follow us: www.facebook.com/nationalpartnership www.twitter.com/npwf

Contact me:

Christine Bechtel Vice President (202) 986-2600

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Melinda K. Abrams, M.S. Vice President The Commonwealth Fund

The Medical Home Experience: Care Coordination and the Patient’s Role in Shared

Decision Making and Team Communication Supported by the Center for PCMH Advancement

THE COMMONWEALTH FUND

Melinda Abrams, M.S. Vice President, Patient-Centered Coordinated Care

The Commonwealth Fund

PCPCC Webinar July 12, 2012

Care Coordination and Patient Engagement in

The Medical Home

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THE COMMONWEALTH FUND

Polling Question

What percentage of U.S. adults have experienced a care coordination problem in the past two years? •  10-15 percent •  40-45 percent •  70-75 percent •  90-95 percent •  No idea

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THE COMMONWEALTH FUND

Poor Coordination: Nearly Half Report Failures to Coordinate Care

Percent U.S. adults reported in past two years:

Source: Commonwealth Fund Survey of Public Views of the U.S. Health Care System, 2011.

No one contacted you about test results, or you had to call repeatedly to get results

Test results/medical records were not available at the time of appointment

Your primary care doctor did not receive a report back from a specialist

Any of the above

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23

18

15

12

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0 20 40 60

Doctors failed to provide important medical information to other doctors or nurses you

think should have it

Your specialist did not receive basic medical information from your primary

care doctor

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THE COMMONWEALTH FUND

Inefficient System: More Than Half of U.S. Adults Experience Wasteful and Poorly Organized Care

Percent reporting in past two years:

Source: Commonwealth Fund Survey of Public Views of the U.S. Health Care System, 2011.

54

36

26

23

0 25 50 75

Doctors ordered a test that had already been done

Time spent on paperwork related to medical bills and health insurance a problem

Any of the above

Health care system poorly organized

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THE COMMONWEALTH FUND

Patient-Centered Care Associated with Better Processes of Care and Better Health Outcomes

Patients with positive patient experience are: • More likely to follow physicians’ advice and medication regimens

• More likely to stay with their primary care provider (improved loyalty and retention) • Less likely to file malpractice complaints

• More likely to report better outcomes post hospital discharge, if their ambulatory care experience was positive • Often more likely to receive better process of care (e.g., preventive care screening, chronic disease management)

Sources: I. Wilson et al, “Cost-Related Skipping of Medications and Other Treatments Among Medicare Beneficiaries Between 1998 and 2000,” Journal of General Internal Medicine, 2005; A. M. Fremont et al., “Patient-centered processes of care and long-term outcomes of acute myocardial infarction,” Journal of General Internal Medicine. 2001;14:800–8; K. Browne et al., “Primary Care analysis & commentary Measuring Patient Experience As A Strategy For Improving Primary Care,” Health Affairs, 2010: 29 (5).

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THE COMMONWEALTH FUND

Patient Activation* Level is Predictive of Behaviors

Research consistently finds that those who are more activated are: – Engaged in more preventive behaviors – Engaged in more healthy behaviors – Engaged in more disease specific self-

management behaviors – Engaged in more health information seeking

behaviors

Source: J. Hibbard, “Patient Activation and Engagement for ACOs,” The Centers for Medicare and Medicaid Innovation Webinar, January 24, 2012. https://acoregister.rti.org/index.cfm?fuseaction=dsp_web J. Greene and J. Hibbard, “Why does patient activation matter? An examination of the relationships between patient activation and health-related outcomes.” Journal of General Internal Medicine, May 2012.

*Activated patients are patients who have the motivation, knowledge, skills, and confidence to make effective decisions to manage their health.

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THE COMMONWEALTH FUND

Level of Patient Activation is Linked with Hypertension Self Care Behaviors

Source: US National sample 2004

Source: J. Hibbard, “Patient Activation and Engagement for ACOs,” The Centers for Medicare and Medicaid Innovation Webinar, January 24, 2012. https://acoregister.rti.org/index.cfm?fuseaction=dsp_web J. Greene and J. Hibbard, “Why does patient activation matter? An examination of the relationships between patient activation and health-related outcomes.” Journal of General Internal Medicine, May 2012.

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THE COMMONWEALTH FUND

Level of Patient Activation is Linked with Diabetes Self-Care Measures

RWJ PeaceHealth Study 2006

Source: J. Hibbard, “Patient Activation and Engagement for ACOs,” The Centers for Medicare and Medicaid Innovation Webinar, January 24, 2012. https://acoregister.rti.org/index.cfm?fuseaction=dsp_web J. Greene and J. Hibbard, “Why does patient activation matter? An examination of the relationships between patient activation and health-related outcomes.” Journal of General Internal Medicine, May 2012.

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THE COMMONWEALTH FUND

Patients with Medical Homes Less Likely to Report Coordination Gaps in the Past Two Years

Percent*

* Test results/records not available at time of appointment, doctors ordered test that had already been done, providers failed to share important information with each other, specialist did not have information about medical history, and/or regular doctor not informed about specialist care. Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.

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THE COMMONWEALTH FUND

Patients with Medical Homes Report Higher Levels of Patient Engagement

* Health care professional in past year has: 1) discussed your main goals/priorities in care for condition; 2) helped make treatment plan you could carry out in daily life; and 3) given clear instructions on symptoms and when to seek care. Base: Has chronic condition. Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.

Percent reporting positive patient engagement in managing chronic condition*

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THE COMMONWEALTH FUND

What is Care Coordination?

“Care coordination is the deliberate organization of patient care activities between two or more participants (including the patient) involved in a patient's care to facilitate the appropriate delivery of health care services.”

Source: Closing see Quality Gap: A Critical Analysis of Quality Improvement Strategies: Volume 7—Care Coordination, Agency for Healthcare Research and Quality: http://www.ahrq.gov/clinic/tp/caregaptp.htm.

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THE COMMONWEALTH FUND

Setting Up Systems to Monitor Performance of Care

Coordination in Medical Homes

Critical to Understand if Patients’ Needs Are Being Met

THE COMMONWEALTH FUND

Polling Question

How often do you collect and discuss performance data about how well you coordinate your patients’ care? • We don’t. Hence, the webinar • We collect lots of data, but never have time to discuss it • Annually • Monthly to quarterly • Everyday

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THE COMMONWEALTH FUND

Seven Key Changes to Set up Performance Monitoring System

1.  Work with a broad stakeholder group 2.  Clarify purpose of measurement 3.  Use standardized measures 4.  Incorporate patients and families feedback 5.  Develop a tracking system 6.  Build and nurture relationships 7.  Use the data

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THE COMMONWEALTH FUND

1.  Work with a Broad Group of Stakeholders to Reach Consensus on Measures

•  Involve executive leadership, clinical teams, front-desk staff

•  Involve patients and families!

•  Ensures buy-in and increases follow-up action

THE COMMONWEALTH FUND

2.  Articulate Clarity of Purpose Recognize the implications of your choice

•  Quality Improvement? •  To modify intervention

•  Accountability or benchmarking? •  To attain incentive, recognition or bonus

•  Evaluation? •  To assess if the model should be sustained or

spread

THE COMMONWEALTH FUND

3.  Use Standardized, Nationally Endorsed Measures

•  Enables fair comparisons about quality of care coordination (referrals, follow-up, transitions, etc.)

•  Enables comparison to national benchmarks

•  Saves time

•  No shortage of measures, but little consistency in use

•  Select measures that matter

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THE COMMONWEALTH FUND

Polling Question

How do you know if your patients think you’re doing a good job coordinating their care? • We survey our patients • We hold focus groups or ask our advisory council • We ask them to use our ‘suggestion box’ • We just know – they complain • We don’t know

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THE COMMONWEALTH FUND

4.  Incorporate Patient and Family Feedback to Assess Quality of Coordination

•  Patient surveys about their experience •  Focus groups •  Patient and family advisory councils •  Comment cards

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THE COMMONWEALTH FUND

5.  Develop a Tracking System that Monitors Performance

•  Incorporate into workflow •  Need written procedures, protocols for how to share

information between providers and between providers and patients

•  Use Information technology •  Care Coordination Agreements (CCAs) can specify

responsibilities of different providers

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THE COMMONWEALTH FUND

6.  Build Relationships with Providers in Your Medical Neighborhood

•  The success of technical system depends on strength of the interpersonal relationships

•  Continue to convene your broad stakeholder group to obtain feedback on process as well as to review performance data

THE COMMONWEALTH FUND

7.  Share Results at Practice and Care-Team Levels to Improve Care Coordination

Measurement Wall at Community Health Partners in Montana:

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THE COMMONWEALTH FUND

Tips for Data Reporting to Drive Quality Improvement

•  Ensure all staff members understand the metrics for success – Collect stories from patients – Review aim of PCMH with patients – Review progress at team meetings, with patient

advisory council, with leadership •  Select a visible or easily accessible location for

data reports, update often Source: Safety Net Medical Home Initiative. Van Borkulo N, Coleman K. Quality Improvement Strategy Implementation Guide, Part 1: Choosing and Using a QI Framework. 1st ed. Phillips K and Burton T, eds. Qualis Health and the MacColl Center for Health Care Innovation at the Group Health Research Institute; August 2011. http://www.safetynetmedicalhome.org/sites/default/files/Implementation-Guide-QI-Strategy-1.pdf

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THE COMMONWEALTH FUND

Polling Question

Which key change discussed today can you implement (or improve) in the next 3 months? •  Convene stakeholder group to devise a measurement strategy •  Clarify the purpose of our measurement activities •  Incorporate patient/family feedback •  Develop a system to make data collection routine •  Improve how we display, share and act on the results

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THE COMMONWEALTH FUND

Thank You!

For more information, please visit: www.commonwealthfund.org

Karen Crow Program Assistant Commonwealth Fund kc@cmwf.org

Ed Wagner, MD, MPH McColl Center, Group Health Research Institute

Jessica Greene, PhD University of Oregon

Judith Hibbard, DrPH University of Oregon Cathy Schoen, MS

Commonwealth Fund

Donna Daniel, PhD Qualis Health

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THE COMMONWEALTH FUND

Appendix: Resources to Help Select Care Coordination Measures

•  AHRQ Care Coordination Measurement Atlas (http://www.ahrq.gov/qual/careatlas/)

•  MacColl/Qualis comparison of care coordination questions from patient experience surveys (http://www.safetynetmedicalhome.org/sites/default/files/Implementation-Guide-Patient-Centered-Interactions-1.pdf)

•  National Quality Forum’s National Priorities Partnership (http://www.qualityforum.org/Setting_Priorities/NPP/National_Priorities_Partnership.aspx)

•  For evaluation, the Patient Centered Medical Home Evaluators’ Collaborative core, recommended measures (limited) (http://www.commonwealthfund.org/Publications/Data-Briefs/2012/May/Measures-Medical-Home.aspx)

•  NCQA PCMH Standards: care coordination measures (http://www.ncqa.org/tabid/631/Default.aspx)

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Questions

Supported by the Center for PCMH Advancement

The Medical Home Experience: Care Coordination and the Patient’s Role in Shared

Decision Making and Team Communication

Thank You

Supported by the Center for PCMH Advancement

The Medical Home Experience: Care Coordination and the Patient’s Role in Shared

Decision Making and Team Communication